Implementation of Complex Suicide Prevention Interventions: Insights into Barriers, Facilitators and Lessons Learned

Figures & data

TABLE 1. Summary of most frequently reported barriers and facilitators across intervention clusters (in descending order of most to least frequently reported) using updated CFIR domains.

Barriers	Facilitators
Outer setting
Local conditions: Economic, environmental, political, and/or technological conditions that create barriers in the outer setting to support implementation and/or delivery of the intervention.	Local attitudes: Sociocultural values (e.g., shared responsibility in helping) and beliefs (e.g., stigma) that support implementation and/or delivery of the intervention.
Market pressure: Competing with and/or imitating peer entities that create barriers to implementation and/or delivery of the intervention.
Local attitudes: Sociocultural values (e.g., shared responsibility in helping) and beliefs (e.g., stigma) that create hindrances in implementation and/or delivery of the intervention.
Critical incidents: Large-scale and/or unanticipated events (economic downturn, pandemic, natural disasters) that disrupt implementation and/or delivery of the intervention.
Partnerships and connections: Managing partnerships with entities external to the inner setting (intervention setting), including referral networks, academic affiliations, and professional organization networks.
Financing: Limitations on availability of funding from external entities (e.g., grants, reimbursement) to implement and/or deliver the intervention.
Inner setting
Compatibility: Challenges with appropriateness of the intervention within intervention settings.	Relational connections: There are high quality formal and informal relationships, networks, and teams within and across the intervention setting (e.g., structural, professional).
Culture: Challenges related to shared norms, attitudes, and beliefs within intervention settings.	Mission alignment: Implementation and delivery of the intervention is in line with the overarching commitment, purpose, or goals within the intervention setting.
Relational connections: Challenges related to formal and informal relationships, networks, and teams within and across the intervention setting (e.g., structural, professional).	Work infrastructure: Organization of tasks and responsibilities within and between individuals and teams, and general staffing levels, support functional performance within the intervention setting.
Available resources: Lack of adequate resources (funding, knowledge and information, materials) to implement and deliver the intervention.	Communications: There are high quality formal and informal information sharing practices within and across the intervention setting (e.g., structural, professional).
Work infrastructure: Organization of tasks and responsibilities within and between individuals and teams, general staffing levels create barriers in effective performance within the intervention setting.	Compatibility: A good fit between the intervention and the setting systems and processes.
Relative priority: Implementation of other initiatives is as/more important than the intervention.
Communications: Formal and informal information sharing practices within and across the intervention setting (e.g., structural, professional) are inadequate.
Mission alignment: The overarching commitment, purpose or goals within the intervention setting are misaligned with the intervention.
Individuals
Need: The individual(s) has deficits related to survival, well-being, or personal fulfillment, which is not particularly addressed by the intervention.	Motivation: The individual(s) involved in the intervention are on board and committed to fulfilling their roles.
Capability: The individual(s) involved in the intervention do not feel they have the interpersonal competence, knowledge, and skills to fulfill role responsibilities.	Capability: The individual(s) has interpersonal competence, knowledge, and skills to fulfill role responsibilities.
Motivation: The individual(s) involved in the intervention are not necessarily engaged with the program or committed to fulfilling role responsibilities.	Need: The individual(s) has deficits related to survival, well-being, or personal fulfillment, addressed by the intervention.
Innovation
Complexity: The complexity in the nature, scope and delivery of the intervention creates barriers in its implementation.	Adaptability: The intervention can be modified, tailored, or refined to fit local context or needs.
Design: Complexities involved in the intervention design (for instance, requiring staggered implementation efforts) hinders implementation and delivery of the intervention.	Design: The simplicity in intervention design and how it is presented aids implementation efforts.
Implementation process
Adapting: Modifying the intervention for an optimal fit within the changing landscape of the intervention setting can create hindrances in the intervention delivery.	Assessing needs and context: Collecting information about priorities, preferences, and needs of people as well as barriers and facilitators on implementation can aid acceptability, adoption as well as quality of intervention delivery.
Engaging – intervention recipients: Attracting and encouraging participation (especially from intervention recipients) in the implementation and delivery efforts can be challenging.	Engaging – intervention recipients: Attracting and encouraging participation (especially from intervention recipients) in the implementation and delivery efforts aids acceptability.

TABLE 2. Implementation process related information reported per intervention cluster.

Intervention/cluster name	Context	Barriers and facilitators	Lessons learned
European Alliance Against Depression (EAAD)/ German Alliance Against Depression (GAAD)/ Optimizing Suicide Prevention and their Implementation in Europe (OSPI)	Country: EAAD – Europe (Initial network of 17 partners, continuously expanding) (2001–present) OSPI – Europe (implemented and tested in Ireland, Germany, Hungary, Portugal) (2009–present)	Barriers Outer setting (local conditions): Heterogeneity in socio-demographic characteristics, healthcare systems, social service organizations and the knowledge and awareness of participating communities Outer setting (critical incidents): Uncontrolled factors such as natural disaster such as floods, economic downturn, elections, other ongoing interventions Facilitators: Individuals (motivation): Interest and will of regional partners – ‘bottom up’ movement	Combining interventions created synergistic and catalytic effects. Importance of a bottom up approach, starting locally, developing community ownership. Advisory groups key in ensuring reciprocity, capacity building and sustainability. Importance of a catalogue of best practice materials Adaptation of intervention activities to the local context is essential. Broader de-stigmatising effects of the intervention may occur. Sustained implementation of activities is important for a significant impact
	Target population: All age groups, different sub-populations
	Intervention delivered by: Program staff, community members and healthcare professionals
	Setting: Community
Lifespan	Context: Australia (2015–2020)	Barriers Outer setting (partnerships and connections): Coordination between multiagency implementation Individual (capability): Limited capacity – skills, knowledge, time, and capacity for engagement Facilitators: Inner setting (relational connections); Individual (motivation): Community buy in and engagement	Community buy in and support is integral – building local ownership Continuous and regular engagement with site coordinators and key partners to address barriers and share learnings. Using collective knowledge and experience to inform strategies for addressing barriers. Key performance indicators on uptake, completion rates, demographics of reach – important to keep on track. Clear procedures related to intervention delivery. An early focus on developing long term plans along with funding
	Target population: All age groups, different sub-populations
	Intervention delivered by: Program staff, community members, organizations
	Setting: Community, health care and schools
SUPRANET	Country: Netherlands (2017–present)	Barriers: Innovation (innovation complexity): Implementation of multiple interventions at the same time Outer setting (market pressure); Inner setting (relative priority): Other ongoing interventions Individual (capability): Limited capacity – Self-perceived incompetence of professionals, burdensomeness of suicide, time and workload Facilitators: Individual (motivation): Community buy in and engagement	Adaptation of intervention activities to the local context is essential. Importance of ongoing training participating stakeholders Public awareness campaign and suicide prevention training for gatekeepers comparatively easier to implement.
	Target population: All age groups, different sub-populations
	Intervention delivered by: Program staff, community members, organizations
	Setting: Community
NOCOMIT J	Country: Japan (2006–2010)	No specific barriers or facilitators mentioned	Adaptation of intervention activities to the local context is essential (specific reference to population size) Leadership involvement important in effective implementation of long-term programs for commitment at multiple levels and establishing community support networks.
	Target population: All age groups, different sub-populations
	Intervention delivered by: Program staff, community members, organizations
	Setting: Community
Community based program in Akita Prefecture	Country: Japan (1999–2004)	No specific barriers or facilitators mentioned	Prioritizing suicide prevention at the local government level Integrating community-based suicide prevention programs with other public health and health promotion programs at the local government level Community engagement from all levels, in different settings: family, school and workplace is key
	Target population: Aimed at the general population but primary target was middle-aged and aged population
	Intervention delivered by: Program staff, community members and healthcare professionals
	Setting: Community
Community based program for the elderly in Yuri town	Country: Japan (1995–2002)	No specific barriers or facilitators mentioned	No specific learnings mentioned
	Target population: 65 years and over
	Intervention delivered by: Program staff, community members and healthcare professionals
	Setting: Community
Community based program for the elderly in Minami district (SUPPRESS)	Country: Japan (1993–2004)	No specific barriers or facilitators mentioned	No specific learnings mentioned
	Target population: 65 years and over
	Intervention delivered by: Program staff, community members and healthcare professionals
	Setting: Community
People Awakening	Country: Alaska, USA (1995–present)	Barriers: Inner setting (culture): Differences in language, culture and worldviews between the research team and the community Inner setting (relational connections); Implementation process (Engaging – intervention recipients): Ensuring and maintaining community ownership and involvement every step of the way Inner setting (culture, available resources-funding): Navigating funding difficulties for cultural interventions in a world of social and biomedical health science. Individual (need, opportunity): Negotiating roles and expectations Facilitators: Inner setting (relational connections); Individual (motivation): Support of community leadership Outer setting (local attitudes); Inner setting (mission alignment, compatibility); Individual (motivation): Commitment to kinship, willingness and responsibility to address concerns of the community. Implementation (engaging – intervention recipients): Intervention delivered by the community	Responsiveness to the needs of the community Collaboration at the heart of intervention design, implementation and evaluation-intervention of the people, for the people and by the people Culture not seen as an add-on to and intervention generalizable across people and over time but as the organizing principle and underlying commitment to guiding theory, power, constructs, measures, processes of collaboration, and goals. Importance of understanding one’s and the community’s position and worldview – maintaining emotional distance in coalescing relationship Participatory relationships fluctuate over time, due to uncontrollable factors. Importance of making measure development responsive to cultural practices, through collaborative processes; and respects population of interest
	Target population: Yup’ik (Alaska indigenous population) Youth – 12–18 years of age
	Intervention delivered by: Community members
	Setting: Community
MATES	Country: Australia (2008–present)	Barriers: Individual (capability): Limited time capacity for engagement Individual (need): Lack of receptivity to help offering Individual (need): Stressors such as lack of job security, personal and family problems Inner setting (culture): Workplace culture, bullying Facilitators: Inner setting (relational connections); Individual (motivation): Community buy in Implementation process (engaging – intervention recipient): Intervention delivered by the community – mates Innovation (innovation design): Simplicity of the model Inner setting (communications, work infrastructure): Clarity of roles and expectations	Intervention delivered by a known person – sense of familiarity and personal relevance. An increased willingness to seek help (along with an uptake of services) when – 1) help is offered by a mate; 2) help is available. Regular contact and check in is helpful. Importance of ongoing training for sustained effects
	Target population: Diverse age groups – engaged in public and private sector construction
	Intervention delivered by: Program staff, trained field officers
	Setting: Community – construction industry setting
MISP-NZ	Country: New Zealand (2010–2012)	Barriers: Outer setting (market pressure): Other ongoing interventions Inner setting (relative priority): Limited engagement of general practitioners in the intervention No specific facilitators mentioned	A brief intervention may not create a significant impact. Adaptation of intervention activities to the local context is essential. Uptake varied for different interventions; best uptake for resources, followed by training and workshops. Importance of reporting contextual information about local health system and preexisting suicide prevention activities in reporting of multilevel interventions.
	Target population: All age groups, different sub-populations
	Intervention delivered by: program staff and community members
	Setting: Community
US Airforce Suicide Prevention Program	Country: USA (1996–2008)	Barriers: Individual (capability): Limited capacity for engagement Individual (need): Stressors such as: ongoing warfare, specific combat exposures, repeated deployments, personal and finance related matters Outer setting (local attitudes): Stigma associated with mental health disorders and psychosocial problems in the military No specific facilitators mentioned	Sustained implementation of a multilevel, community based and overlapping approach can reduce suicide rates Program efforts must be continuously supported and monitored for sustained effects Elimination of key confounders for risk of suicide such as socioeconomic status and access to health care is important Applicability of the intervention in other setting such as: armed services worldwide, larger corporations, states or smaller countries, and schools and universities.
	Target population: Active duty US Air Force personnel between 1990–2002.
	Intervention delivered by: Program staff, community members
	Setting: Community – Airforce personnel
Police Suicide Prevention Program – Together for life	Country: Canada (2000–2010)	Barriers: Implementation process (adapting): Maintaining momentum of the program, in tandem with changes within the workforce Facilitators: Inner setting (relational connections): Regard and appreciation for Police Counseling service – who implemented most of the program Implementation (engaging – intervention recipients): Investment of supervisors and volunteer officers as helpers in implementing the program Inner setting (work infrastructure): Stability in the functioning, training, and recruitment patterns of the police force during the implementation period	Persistent and intensive activities in a small, closed environment may have impact the culture – possible to educate all members and achieve long lasting impact. Applicability of the program in other settings and environments.
	Target population: Police force
	Intervention delivered by: Program staff, community members (police force) and healthcare professionals
	Setting: Community – police force
National Suicide Prevention Trial	Country: Australia (2016–2021)	Barriers: Individual (motivation); Inner setting (relational connections): Community readiness and capacity for engagement Inner setting (relative priority, available resources): Limited time, funding and capacity of the PHNs – Difficulties in initiating and driving systems level change; competing priorities Inner setting (work infrastructure): Limited access to healthcare services upon referrals Inner setting (compatibility, available resources): Engaging with high priority populations Inner setting (work infrastructure, communications): Lack of role clarity, predetermined objectives and thereby roles Facilitators: Individual (motivation, capability): Personal relevance, engagement, and investment of the community to address this concern	Embracing a pragmatic approach to engage in select activities that best utilized available resources to respond to high priority needs of the community – strict adherence to a model of intervention may not work. A whole of community empowerment engagement essential for implementing intervention activities; significance of working groups – bottom up approach Regularly reflecting on what went well or not – important for tailoring strategies. Importance of engaging volunteers, community groups and services to undertake suicide prevention activities in building community capital. More support to PHN staff and ongoing consultations to implement activities.
	Target population: All age groups different sub-populations
	Intervention delivered by: Program staff, community members, healthcare professionals
	Setting: Community
National model adolescent suicide prevention project	Country: New Mexico, USA (1988–2002)	Barriers: Inner setting (compatibility): Project staff seen as outsiders Facilitators: Individual (motivation, capability): Professional qualification and certification of staff – trust in the program Individual (motivation); Inner setting (mission alignment): Engagement of the community, high regard for project services	Sustained efforts needed to meet community’s mental health needs Importance of trained individuals for delivering interventions Sensitivity to cultural norms and practices of the community Importance of adaptability of program elements to local context Importance of having a broad focus for suicide prevention programs in the community
	Target population: Youth and young adults up to 25 years of age
	Intervention delivered by: Program staff, community members, healthcare professionals
	Setting: Community
Zero Suicide Framework	Country: Australia, USA (2011–present) Target population: Diverse age groups presenting to health care facilities Intervention delivered by: Healthcare professionals, program staff Setting: Healthcare setting	Barriers: Individual (need): Consumers’ lack of trust in healthcare, due to past traumatic experiences Inner setting (compatibility, mission alignment): Tensions between expectations/needs of consumers and their carers and priorities/needs of the organization. Individual (capability): Limited time and capacity – practitioner burnout Inner setting (work infrastructure, culture): Organizational structure and workplace culture Facilitators: Individual (capability): Clinician’s confidence in their knowledge and skills to implement the framework Individual (need): Consumers’ belief and investment in the services offered to them	Measuring what and how the framework is implemented are important quality improvement goals Need for a collaborative response from the whole health care system Importance of all components of the framework – not be viewed as optional extras – maintaining fidelity to the components Creating spaces for collaborative learning Importance of adapting elements of the program to suit the needs of the context Importance of ongoing training for sustainability Integration of the Zero Suicide Framework within healthcare system and practices
Te Ira Tangata	Country: New Zealand (2009–2012)	Barriers: Outer setting (local attitudes); Inner setting (compatibility): Consumers’ ambivalence about engagement in treatment Individual (need): Consumers feeling overwhelmed either by the services or personal problems Outer setting (critical incidents): Life events such as moving residence – prevented consumers from engaging in a short term treatment Outer setting (local attitudes); Inner setting (compatibility): Difficulties in obtaining consent Facilitators: Inner setting (mission alignment); Innovation (adaptability): Familiarity with the culturally appropriate delivery of the intervention	Importance of delivering interventions in a culturally appropriate manner – acceptability of the intervention
	Target population: All adults (above 17) presenting to the emergency department with self-harm
	Intervention delivered by: Healthcare professionals, program staff
	Setting:
SPIRIT	Country: India (2018–present)	No specific barriers and facilitators mentioned – trial ongoing	Importance of involving multiple sectors including health, education and agriculture at the state government and local village level; building an effective partnership is crucial Importance of adaptability of intervention activities and dissemination materials to suit the needs of the context.
	Target population: All age groups different sub-populations
	Intervention delivered by: Program staff, community health workers, community members
	Setting: Community
School based multimodal program	Country: Netherlands	No specific barriers or facilitators mentioned – trial ongoing	No specific learnings mentioned – trial ongoing
	Target population: Youth – 11–15 years of age
	Intervention delivered by: Program staff, community members, healthcare professionals
	Setting: School
Colorado National Collaborative	Country: USA (2014–present)	Barriers: Outer setting (local conditions): Preexisting community dynamics Innovation (design): Staggered implementation efforts Outer setting (financing): Funding limitations Outer setting (market pressure): Integrating the program with other community engaged programs Inner setting (relational connections): Engaging in partnerships with a broad range of interest groups Outer setting (local conditions): Emerging and continuing crises such as coronavirus pandemic, seasonal wildfires Facilitators: Implementation process (assessing needs and context): Comprehensive understanding of county and state level data	Importance of tailoring interventions based on collaborative discussions to address challenges of time and inherent diversities between groups Impact measures are important indices for quality improvement but do not offer a sense of whether programs are working – use of novel designs which offer a more comprehensive picture may be helpful.
	Target population: All age groups different sub-populations
	Intervention delivered by: Program staff, community members, healthcare professionals
	Setting: Community

Note. Abbreviations and their expansions.

MATES: No expansion.

MISP-NZ: No expansion.

NOCOMIT-J: No expansion.

SPIRIT: Suicide Prevention and Implementation Research Initiative.

SUPRANET: Suicide Prevention Action NETwork.

OSPI: Optimizing Suicide Prevention Programs and their Implementation in Europe.

FIGURE 1. Barriers & facilitators to implementing complex suicide prevention interventions, mapped on updated CFIR domains.